Intertrigo—Helping Case Managers Iron Out Skin Fold Challenges

Michelle Christiansen, MS, PA, CN-E, CCDS

Preventing harm within health care environments is a big challenge, yet it is also an expectation for case managers, their patients and their families. As the largest organ in the human body, our skin is vulnerable to a multitude of threats. Protecting patients from skin damage is a critical part of providing care, but as conditions become more complex, it’s more challenging than ever to keep skin safe and healthy.

The harmful effects of water on the skin have long been known. Several causes of skin breakdown, seen in clinical practice, are related to the overexposure of the skin to moisture. The term moisture-associated skin damage (MASD) is used to describe the spectrum of damage that occurs as a result of prolonged exposure of a patient’s skin to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva (1). However, MASD is a general umbrella term and is made up of four commonly encountered separate conditions, which often coexist. These conditions are incontinence-associated dermatitis (IAD), intertriginous dermatitis, commonly referred to as “intertrigo,” periwound moisture–associated dermatitis, and peristomal moisture–associated dermatitis.

Normal skin barrier and control of moisture

One of the major functions of healthy skin is the maintenance of a physical protective barrier against the external forces that can be detrimental to the body, such as mechanical trauma, noxious irritants, excessive fluids, and infectious pathogens. This is achieved by the uppermost layer of the skin, the epidermis, and in particular the outermost part of the epidermis, the stratum corneum. The stratum corneum is composed of tightly packed, flattened, proteinrich cells called corneocytes, which are held together by a lipid-rich matrix. The stratum corneum (horny layer) also contains a mix of substances that actively attract and hold water in the corneocytes, collectively termed natural moisturizing factor (NMF). NMF acts by absorbing water from the atmosphere and deeper layers of the skin and enables the outermost layers of the skin to remain hydrated, despite the drying action of the environment (2).

This delicate balance is one of the most important factors in maintaining the flexibility and elasticity of the skin and an effective barrier against the external environment (3). Disruption of this balance leads to either excessive skin dryness or prolonged exposure to various sources of moisture such as urine or stool, perspiration, wound exudate, and secretions including mucus and saliva. Overexposure to moisture disrupts the intricate lipid-rich matrix of the outermost layer of the skin, the stratum corneum, as well as the intercellular connections between the corneocytes, which compose the stratum corneum (4, 5). Furthermore, wet skin has a high coefficient of friction, which makes it susceptible to damage from both friction and shearing forces (5).

Moisture-Associated Skin Damage

Disruption of the skin barrier increases its permeability to irritants, leading to inflammation or dermatitis (5). The spectrum of conditions characterized by inflammation and erosion of the skin resulting from continued exposure to moisture are described by the umbrella term “MASD.” MASD includes four distinct clinical entities: (1) IAD, (2) intertrigo, (3) peristomal dermatitis or peristomal MASD (PMASD), and (4) periwound moisture–associated dermatitis or periwound skin damage (4,5).

Intertrigo is a form of MASD that affects opposing skin folds of the body and often coexists with IAD (4). The prevalence of intertrigo ranges from 2%–6% in hospital patients to 6%–17% in nursing home patients and to 9%–20% in home care patients. Large skin folds of the body such as the axillary, inguinal, and intergluteal areas as well as the inframammary areas in females are commonly affected by intertrigo.

Michelle Christiansen, MS, PA, CN-E, CCDS, is the Vice President of Clinical Sales, Marketing, and Business Development for several divisions at Medline Industries, LP. Some of her specialties have included surgical site infection prevention, wound care, urology (adult/pediatric), interventional radiology, operating room turnover improvement and safety, and patient positioning and pressure ulcer prevention as well as skin care and peripherally inserted central catheter insertion (PICC) and maintenance.

Abdominal and pubic panniculi may be affected in individuals with obesity. However, other sites of the body like neck creases, antecubital, popliteal, umbilical, perianal, and interdigital areas as well as the folds of eyelids and retroauricular areas may also be involved (4, 6, 7, 8).

Intertrigo

Intertrigo is a common dermatological condition that occurs in skin folds as a result of moisture becoming trapped due to poor air circulation. The major underlying causes of intertrigo are perspiration and lack of air circulation within the skin folds; this leads to skin-on-skin friction and eventually results in skin inflammation and maceration. Bacterial infections are a common complication associated with intertrigo. Intertrigo is primarily caused by trapped moisture in skin folds that causes the skin to “stick” together, thereby increasing friction. This can occur in any areas of the body where there are two skin surfaces in close contact with each other, such as between the toes or fingers, but is more common in the natural large skin folds of the body (axillary and inguinal areas) as well as under the breasts in females (9). Babies are particularly prone to developing intertrigo in the neck folds because they have short necks, flexed postures, and drool (10).

Several factors increase the likelihood of intertrigo developing in obese individuals. First, the skin folds are more pronounced, and intertrigo commonly occurs under the abdominal or pubic panniculi. Second, the associated problems of increased sweating and reduced dexterity can make it difficult to ensure these areas are kept clean and dry. Initially intertrigo presents as mild erythema in the skin folds, but it may progress to more severe inflammation with erosion, oozing, exudation, maceration, and secondary infection (11). This combination of warm, moist, and damaged skin provides ideal conditions for microorganisms to breed. Fungal infections are common, including those due to Candida species and dermatophytes such as Trichophyton often complicate interdigital intertrigo. Numerous bacterial species often coexist, such as Staphylococcus, Streptococcus, Pseudomonas, and Proteus, and include antibiotic-resistant strains (methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant Staphylococcus aureus [VRSA]) (10). A particular variation of secondary infection seen in intertrigo is caused by an organism called Corynebacterium minutissimum. This bacterial infection leads to a condition known as erythrasma, in which red/brown skin discoloration occurs in the intertriginous areas. If not effectively dealt with, any initial secondary infection can easily progress into more serious soft tissue infection, such as cellulitis or even systemic sepsis (9).

The Role of the Case Manager for Patients with Intertrigo and Related Conditions

Catherine M. Mullahy, RN, BS, CRRN, CCM, FCM Executive Editor, CareManagement

Patients who may have intertrigo are typically not referred for case management intervention because of this diagnosis but rather because of a concomitant diagnosis such as hyperhidrosis, diabetes, and obesity as well as other conditions that render patients compromised physically and either mostly immobile or bedridden. Intertrigo can be a challenging disorder to manage for both the patient and for the health care team. The initial and most important step in the case management process is screening and assessing patients at the earliest opportunity. Knowing the risk factors that can contribute to this often-debilitating condition is important; the case manager should be aware of the medical conditions mentioned in this article and should also carefully assess the patient’s social determinants of health and behavioral health factors.

Individuals who have health literacy issues, who live in underserved areas, who lack family support, and who are coping with transportation and financial barriers will need to have their care carefully coordinated and to have ongoing collaboration with the health care professionals and service providers that will be involved in their care.

Addressing the very real and significant psychosocial factors that impact so many patients with intertrigo is an extremely significant role for the case manager because patients who develop intertrigo and related conditions are frequently embarrassed and delay obtaining treatment in a timely manner, which of course only serves to complicate the situation and to increase the costs of care. Because some patients with intertrigo often have an unpleasant appearance and an objectionable odor, members of the patient’s health care team might have an aversion to caring for these individuals. Case managers can make an invaluable contribution by serving as the patient’s advocate and providing education and support to hands-on providers.

Because intertrigo may be a lifelong chronic condition with recurrent exacerbations and costly complications, the case manager will likely need to provide ongoing education and support for the patient and the patient’s family.

Outcomes can be determined by objectively assessing the results obtained from case management intervention. While cost savings obtained from case management interventions for intertrigo and related conditions are not widely available, the goal of case managers is to reduce their patients’ complications and to provide education and resources for their patients.

Intertriginous dermatitis, or intertrigo, is a form of moisture-associated skin damage that affects opposing skin folds of the body and often coexists with incontinence-associated dermatitis. The prevalence of intertrigo ranges from 2%–6% in hospital patients to 6%–17% in nursing home patients and to 9%–20% in home care patients.

Important Risk Factors

Bedridden and elderly individuals as well as infants are commonly affected by intertrigo because of reduced immunity, immobility, and incontinence (7). Infants are also prone to develop intertrigo because of drooling, short neck structure with prominent skin folds, and a flexed position (4, 6, 12). Obesity and hyperhidrosis are important risk factors for intertrigo. Predisposing factors for intertrigo include diabetes, urinary or fecal incontinence, poor personal hygiene, malnutrition, immunosuppression, occlusive clothing, and a hot and humid climate.

People of size may also develop additional skin folds, including lateral folds above the waist, folds across the back just below the scapulae, abdominal folds, pannus, and folds in the legs and arms. “Angel wings” develop both in overweight individuals, even with a body mass index <30 kg/m2, and in the elderly who have lost height. In patients with a body mass index >40 kg/m2, skin also folds over at the waist laterally and then centrally as weight increases. Pannus is graded from 1 to 5, with a grade 1 pannus apron reaching the hairline and mons pubis but not the genitals and a grade 5 pannus apron reaching to the knees. The most prevalent locations for problems were the groin, limbs, beneath the breasts, and the abdomen.

Moisture barrier function is also impaired in obese individuals, with increased sweating after overheating among obese compared with lean individuals. These individuals are less efficient than lean comparators in regulating body temperature by sweating. This inefficiency increases the duration of sweating and the exposure of the skin to moisture. Sweating is most pronounced in skin folds, where moisture is prevented from evaporating. Obese individuals also have more alkaline skin pH than lean individuals.

Etiology

The main factor in the development of intertrigo is occurrence of mechanical skin-to-skin friction. Lack of air circulation in the skin folds traps moisture in the form of sweat, leading to overhydration and maceration of the skin. Feces, urine, wound exudate, and vaginal discharge may aggravate intertrigo. Maceration enhances friction between opposing skin surfaces and initially appears as minimal erythema of the skin folds (4). Intertrigo has an insidious onset, with symptoms such as itching, pain, burning, prickling, or stinging sensations at the site of the skin folds. Although intertrigo presents initially as mild erythematous patches mirrored on both sides of the skin fold, the lesions may progress quickly to exudative erosions, fissures, macerations, or crusts (13). Worsening erythema, pustules, or vesicles and malodor may suggest development of a secondary cutaneous infection (6, 7, 14).

Complications

A variety of microorganisms including different gram-positive or gram-negative bacteria or fungi (including yeasts, molds, and dermatophytes) can complicate intertrigo. Warm, moist, macerated skin, may become inflamed and denuded and can provide ideal conditions for these pathogens to breed. Bacterial species found in the affected areas include staphylococci such as Staphylococcus aureus (including antibiotic-resistant strains), group A β -hemolytic Streptococcus, Pseudomonas, Proteus mirabilis, Proteus vulgaris, enterococci , and vancomycin-resistant enterococci (13). The bacterium C. minutissimum causes a particular variation of secondary infection seen in intertrigo called erythrasma (4). An infected intertrigo lesion may result in serious cellulitis, especially in patients with diabetes. Additionally, skin fissuring and ulceration can occur within the deep skin folds in individuals with obesity leading to pain, disability, and, potentially, sepsis. Among fungi, Candida albicans is most commonly associated with secondary infection in individuals with intertrigo (6, 12). However, complications resulting from fungal infection in intertrigo-affected areas are beyond the scope of this paper.

Physical examination

The appearance of intertrigo is dependent on the skin area involved and the duration of inflammation. Intertrigo initially presents as mild erythematous patches on both sides of the skinfold. The erythematous lesions may progress to weeping, erosions, fissures, maceration, or crusting. Worsening erythema or inflammation could suggest the development of a secondary cutaneous infection (1, 15).

Pustules or vesicles may herald infection. In the perineum, depths of the skin folds are involved, whereas with purely irritant diaper dermatitis, only convex surfaces are involved. Bluish-green staining of the diaper or underclothing may indicate pseudomonal intertrigo, which can be treated with vinegar soaks (6, 16). Intertrigo infected by Candida species often presents with satellite lesions. Any skin fold may be involved with intertrigo.

Intertrigo is a common dermatological condition that occurs in skin folds as a result of moisture becoming trapped due to poor air circulation. The major underlying causes of intertrigo are perspiration and lack of air circulation within the skin folds; this leads to skin-on-skin friction and eventually results in skin inflammation and maceration.

Treatment

Treatment of intertrigo aims at reducing symptoms and minimizing the risk for complications related to secondary infection. Management practices generally focus on removal of predisposing factors, including minimizing moisture and friction in the involved areas. These are followed by appropriate use of topical or systemic antimicrobial (antibacterial or antifungal) agents as well as low-potency corticosteroids, if required (6, 14). Preventive measures are important because they may help with management of current intertrigo and may also help avoid occurrence of future episodes (14, 16). The following are measures to prevent intertrigo:

1. An interventional skin care program that removes irritants from the skin, maximizes its intrinsic moisture barrier function, and protects the skin from further exposure to irritants

2. Use of devices or products that wick moisture away from affected or at-risk skin

3. Use of a moisture-wicking textile with hydrogen peroxide between affected skin folds.

4. Continue treatment until intertrigo has been controlled

5. Treat secondary infection with appropriate systemic and topical agents

6. Revisit the diagnosis in cases that do not respond to usual therapy

7. Initiate a prevention program that can include weight loss, a skin-fold hygiene program, and early detection and treatment of recurrence

Prevention

As the common causative agent in MASD is overexposure of the skin to moisture, the main preventative measure is avoiding excessive contact of the skin with moisture. During patient instruction, emphasize topics such as weight loss (in patients of size), glucose control (in patients with diabetes), good hygiene, and the need for daily skin care and monitoring. These are:

1. Minimize skin-on-skin contact and friction

2. Remove irritants from the skin and protect the skin from additional exposure to irritants

3. Wick moisture away from affected and at-risk skin

4. Consider using a moisture-wicking textile with hydrogen peroxide between skin folds

5. Educate patient about proper skin fold hygiene

Skin folds should be kept as clean and dry as possible to minimize friction. Gentle cleansing with a pH-balanced no-rinse cleanser is recommended. Irritated skin folds should be patted dry rather than wiped or rubbed (13). Loose-fitting lightweight clothing made of natural fabrics or athletic clothing that wicks moisture away from the skin are good choices. Open-toed shoes may be beneficial in preventing toe-web intertrigo (6). However, closed-toe shoes would be recommended for patients with diabetes, and a moisture-wicking textile with hydrogen peroxide could be woven between the toes to help translocate moisture.

Moisture-wicking textile with hydrogen peroxide

Various standard treatments for intertrigo, such as drying agents, barrier creams, topical antifungals, and absorptive materials, may be ineffective in some patients. Moisturewicking textile with hydrogen peroxide is a medical device that helps to wick moisture away from the skin folds. The textile is effective for signs and symptoms of intertrigo, such as maceration, denudement, inflammation, pruritus, erythema, and satellite lesions.

This textile is a soft, thin, smooth, polyurethane-coated polyester fabric that helps with management of moisture and provides comfort and odor control; the softness of the textile provides a friction-reducing surface that reduces the risk of skin tears. The moisture from the skin fold is translocated towards the end of the fabric hanging outside the skinfold. Additionally, hydrogen peroxide is encapsulated in a binder, leading to its slow release over time when exposed to moisture. Hydrogen peroxide is a known germicidal agent that prevents the growth of bacteria in the fabric throughout the duration of use. Hydrogen peroxide shows activity against a wide variety of microorganisms, including bacteria, yeast, fungi, viruses, and spores. Hydrogen peroxide produces destructive hydroxyl free radicals that can attack membrane lipids, DNA, and other essential cell components.

As the common causative agent in moisture-associated skin damage is overexposure of the skin to moisture, the main preventative measure is avoiding excessive contact of the skin with moisture. During patient instruction, emphasize topics such as weight loss (in patients of size), glucose control (in patients with diabetes), good hygiene, and the need for daily skin care and monitoring.

For patients who experience incontinence, good continence care is central to success after each major incontinence episode, particularly if feces are present. Ideally the skin care provided for patients with any form of MASD should be based on a structured regimen and involve the use of a skin cleanser and a protectant. The use of ordinary soap and water should be avoided, as in most cases the pH of the soap is too alkaline and may contribute to the skin irritation (17).

After cleansing, the skin needs to be protected against subsequent contact with moisture by using a skin protectant or barrier product. These are designed to repel moisture and protect the skin from the harmful effects of incontinence. Basic barrier preparations consist of a lipid/water emulsion base with the addition of metal oxides (eg, zinc or titanium) that form a thin layer on the surface of the skin to repel potential irritants. The more sophisticated preparations often contain a water-repellent, silicone-based ingredient. Unfortunately, some of these ingredients may cause irritation in sensitive individuals, which should always be kept in mind, particularly if the skin irritation appears to worsen when using any preparation.

Many cleansing products combine a cleanser with a protectant and moisturizer and are pH balanced to help maintain the normal slightly acidic skin pH range of 5.5-5.9, making it easier for patients to adhere to a skin care protocol (18). Similar products should be used for individuals whose skin has already broken down. The problem should be reassessed and the likely cause should be identified. In severe excoriation of the skin, more active measures may need to be taken to contain either urine or feces to protect the skin and to reduce the area of skin exposed to stool or urine. For individuals with an ostomy, changes to the pouch system being used and the introduction of a silicone-based protectant can help. These actions need to be combined with the initiation of a structured skin care regimen.

If assessment of the skin breakdown suggests a fungal infection is present, an antifungal cream will be needed. If bacterial infection is suspected, the use of topical or systemic antimicrobials may be indicated, ideally following sensitivity results and in accordance with local antimicrobial prescribing policy. In the case of intertrigo, care has to be taken to ensure all the skin folds are carefully examined and efforts made to improve air circulation. The use of excessive talcum powder, gauze, towels, or coffee filters between the skin folds should be avoided as these practices may increase the risk of fungal infection and increase moisture trapping (9). The management of periwound dermatitis is based on the same principles as already outlined but is often more of a balancing act in trying to control excessive moisture without causing excessive drying of the skin (19). Most guidelines for the management of heavily exudating wounds advocate using highly absorbent dressings, more frequent dressing changes, and the use of a skin protectant on the periwound skin; in addition, the use of a collecting device should be considered (20).

Learning points

• MASD is an umbrella term for skin breakdown caused by a range of factors in which the skin is exposed to excessive moisture

• Intertrigo is one type of MASD and is an inflammatory condition of skin folds, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation.

• Intertrigo commonly affects the axilla, perineum, inframammary creases, and abdominal folds. Uncommonly, it can also affect the neck creases and interdigital areas.

• Prevention and treatment require regular assessment, with an appropriate skin care regimen that protects the skin from excessive wetness, controls the source of the excessive moisture, and treats secondary infection.

Conclusion

MASD is a common problem encountered in many patient groups. It is generally accepted that MASD consists of four main separate conditions, each having slightly different etiologies. These are IAD, intertrigo, periwound moisture–associated dermatitis, and peristomal moisture–associated dermatitis. Whatever the cause of the excessive moisture, effective interventions should consist of adopting a structured skin care regimen to cleanse and protect the skin, using methods to keep the skin dry by wicking away excessive